Dealing with risks in patient care
Quality management
Claudia-Christine Szulfer-Pollak
QMB
Bolardusstraße 20
26721 Emden
Phone:
04941
-94-1140
Mail:
ed.k-e-u@kallop-refluzs.enitsirhc-aidualc
Claudia-Christine Szulfer-Pollak
QMB
Bolardusstraße 20
26721 Emden
Phone:
04941
-94-1140
Mail:
ed.k-e-u@kallop-refluzs.enitsirhc-aidualc
Geschäftsführung Pflegedirektion Ärztlicher Direktor IT-Abteilung Betriebsrat OP-Management Qualitätsmanagement
Conference frequency: halbjährlich
Risk management
Geschäftsführung Pflegedirektion Ärztlicher Direktor IT-Abteilung Betriebsrat OP-Management Qualitätsmanagement
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available OM-Handbuch (31.10.2018) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management OM-Handbuch (31.10.2018) |
| RM05 |
Pain management OM-Handbuch (31.10.2018) |
| RM06 |
Fall prophylaxis OM-Handbuch (31.10.2018) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) OM-Handbuch (31.10.2018) |
| RM08 |
Regulated handling of custodial measures OM-Handbuch (31.10.2018) |
| RM09 |
Regulated handling of occurring malfunctions of devices OM-Handbuch (31.10.2018) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM14 |
Preoperative summary of predictable critical surgical steps, surgical time and expected blood loss OP-Planung (13.11.2016) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Fall-Besprechung (12.11.2016) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Patientenidentifikation (30.10.2016) |
| RM17 |
Standards for recovery and postoperative care Standard operating procedures (30.05.2017) |
| RM18 |
Discharge management OM-Handbuch (31.10.2018) |
Fault reporting systems
Conference committee
Conference frequency: halbjährlich
Measures
Patientenidentifikationsarmbänder Team-time-out Vier-Augen-Prinzip bei Medikamenten Sicherheit im Umgang mit Medizinprodukten POCT-Beauftragte Anwendung von Assessmentinstrumenten Hygienemanagement strukturierte Fallbesprechungen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 30.08.2017 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken bei Bedarf |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors) |
| EF13 |
DokuPIK (Documentation of Pharmaceutical Interventions in Hospitals at the Federal Association of German Hospital Pharmacists (ADKA) |